CustomCo COLAa..CO �®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
�VR
01/18/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Jackie Damon
NAME:
UNICO Group
PHONE (402) 434-7200 FAX (402) 434-7272
AIC No Ext : A/C, No):
EMAIL jdamon@unicogroup.com
ADDRESS:
1128 Lincoln Mall
INSURER(S) AFFORDING COVERAGE
NAIC #
Suite 200
INSURERA: United Fire & Casualty
13021
Lincoln NE 68508
INSURED
INSURER B : Flr8tComp
27626
INSURER C :
Custom Concrete Designs, Inc.
INSURER D :
1804 Paul Street
INSURER E :
INSURER F :
Omaha NE 68102
COVERAGES CERTIFICATE NUMBER: CL2311689577 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EFF
MMIDD
POLICY EXP
MM/DDIYYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE � OCCUR
RENTED
DA AGE ToEa occu r nce
FIRMM S S
$ 1,000,000
MED EXP (Any one person)
$ 5,000
PERSONAL& ADV INJURY
$ 1,000,000
A
60540730
11/09/2023
11/09/2024
GEN'LAGGREGATELIMITAPPLIESPER:
GENERAL AGGREGATE
$ 2,000,000
X POLICY ❑ PEt° LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
X
BODILY INJURY (Per person)
$
ANY AUTO
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
60540730
11/09/2023
11/09/2024
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY(par..
X
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
A
EXCESS LIAB
CLAIMS -MADE
60540730
11/09/2023
11/09/2024
DED I X1 RETENTION $ 0
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? FYINIA
(Mandatory in NH)
WC0192635-06
11/09/2023
11/09/2024
X STATUTE ORH
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of Blair
ACCORDANCE WITH THE POLICY PROVISIONS.
218 S 16th Street
AUTHORIZED REPRESENTATIVE
Blair NE 68008
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD